R. Patrick Yeatts

5-Fluorouracil for the treatment of intraepithelial neoplasia of the conjunctiva and cornea

OBJECTIVE To evaluate the efficacy of pulse dosing of topical 5-fluorouracil (5-FU) in the treatment of conjunctival and corneal intraepithelial neoplasia. DESIGN Prospective, noncomparative case series. PARTICIPANTS Seven patients with histologic evidence of intraepithelial neoplasia were identified by conjunctival biopsy or tumor excision. METHODS Seven patients with a minimum of 7 months of follow-up were treated with pulsed dosing of 1% 5-FU. Topical 1% 5-FU was administered four times daily for 2 to 4 days for each cycle. The number of initial treatment cycles was two to six, with the time between cycles being 30 to 45 days. MAIN OUTCOME MEASURES The presence or absence of clinically evident intraepithelial neoplasia was evaluated after each treatment interval. Patients were also monitored for adverse reactions to the use of topical 5-FU. RESULTS Four patients remain disease free with a mean follow-up of 18.5 months (range, 7-36 months) with no additional treatment after the initial treatment cycles (mean, 3.75 cycles; range, 2-5 cycles). Three patients had recurrence of disease after the initial treatment cycles. Two patients were treated with additional cycles for recurrent disease (six cycles in one patient and five cycles in the other patient) and are free of disease at 20 and 21 months after treatment, respectively. One patient had persistent disease despite treatment with topical 5-FU and was treated with topical mitomycin C with resolution of the disease without recurrence for 16.5 months. No adverse reactions to pulse dose treatment with topical 5-FU were noted. CONCLUSIONS Pulsed dosing with 1% topical 5-FU for the treatment of conjunctival and corneal intraepithelial neoplasia, alone or as an adjunct to excision of bulky disease, is a well-tolerated and effective method of treatment.

Topical 5-Fluorouracil in Treating Epithelial Neoplasia of the Conjunctiva and Cornea

PURPOSES To evaluate the efficacy of topical 5-fluorouracil (5-FU) in treating conjunctival and corneal epithelial neoplasia. METHODS Three patients underwent surgical excision of bulky disease followed by topical 1% 5-FU in artificial tear base for 2 to 3 weeks or until epithelial separation occurred. An additional three patients underwent treatment with topical 1% 5-FU alone. RESULTS Minimum follow-up was 6 months. In one patient with conjunctival in situ carcinoma and no detectable normal conjunctiva, who had normal findings on conjunctival histologic examination after application of topical 5-FU, a focus of invasive disease requiring orbital exenteration. One patient had a favorable response to 5-FU therapy but required a repeat excision for control of bulky disease. Four patients have remained disease-free for 10, 13, 18, and 30 months after topical 5-FU therapy. CONCLUSION With its potential selective toxicity on dysplastic epithelium, topical 5-FU shows promise as an adjunctive treatment for managing conjunctival and corneal epithelial neoplasia.

Medial rectus muscle injuries associated with functional endoscopic sinus surgery: Characterization and management

Objective To characterize and evaluate treatment options for medial rectus muscle (MR) injury associated with functional endoscopic sinus surgery (FESS). Design Retrospective interventional case series Participants A total of 30 cases were gathered from 10 centers. Methods Cases of orbital MR injury associated with FESS surgery were solicited from members of the American Society of Ophthalmic Plastic & Reconstructive Surgery (ASOPRS) through an e-mail discussion group. Main Outcome Measures Variables assessed included patient demographics, computerized tomography and operative findings, extent of MR injury and entrapment, secondary orbital/ocular injuries, initial and final ocular alignment and ductions, and interventions. Results A spectrum of MR injury ranging from simple contusion to complete MR transection, with and without entrapment, was observed. Four general patterns of presentation and corresponding injury were categorized. Conclusions Medial rectus muscle injury as a complication of FESS can vary markedly. Proper characterization and treatment are important, particularly with reference to the degree of direct MR injury (muscle tissue loss) and entrapment. Patients with severe MR disruption can benefit from intervention but continue to show persistent limitation of ocular motility and functional impairment. Prevention and early recognition and treatment of these injuries are emphasized.

Orbital solitary fibrous tumor: radiographic and histopathologic correlations.

OBJECTIVE To correlate the clinicopathologic and radiographic features characteristic of orbital solitary fibrous tumor (SFT). METHODS The diagnostic features and clinical outcome of seven adults with orbital SFT are retrospectively outlined. Orbital imaging was performed by ultrasonography, computed tomography, or magnetic resonance imaging. Some cases were imaged by multiple modalities. Histopathologic examination of each tumor specimen included standard light and immunohistochemical stains. RESULTS Heterogeneous internal composition was better appreciated on magnetic resonance imaging than on computed tomography. All cases undergoing magnetic resonance imaging showed T1 isointensity and T2 hypointensity relative to gray matter. Strong, generalized immunohistochemical reactivity to vimentin and CD34 validated the diagnosis of SFT and differentiated the specimens from other spindle cell neoplasms. After complete tumor resection, our patients remain tumor free with postoperative intervals of 15 to 45 months. CONCLUSIONS Solitary fibrous tumor has now been reported in 26 orbits. No physical finding is pathognomonic, but several imaging traits are highly characteristic. Intralesional image heterogeneity and a predominantly low T2 signal intensity are distinctive of SFT. Complete tumor resection and immunohistologic specimen evaluation are emphasized. Clinicians should consider the diagnosis of SFT when confronted with an adult patient having an orbital soft tissue mass demonstrating the distinctive magnetic resonance imaging findings.

Spindle Cell Lipoma of the Orbit

A spindle cell lipoma was partially removed from the left orbit of a 27-year-old man. Computed tomography showed a large, mildly enhancing, primarily intraconal mass. The circumscribed, nonencapsulated mass was composed of mature adult lipocytes, spindle cells, and capillaries. The spindle cells lacked a basal lamina and contained a single elongated nucleus. Cells containing osmiophilic material were rounded with nucleus displaced to one margin. Because of the tumors size and proximity to vital structures, total excision was not possible. Such tumors are more frequent in the subcutaneous tissue of the shoulder and posterior aspect of the neck. This benign lesion may be mistaken for other spindle cell tumors, including liposarcoma, angiolipoma, neurilemmoma, and hemangiopericytoma.

Primary signet ring cell carcinoma of the eyelid: report of a case demonstrating further analogy to lobular carcinoma of the breast with a literature review.

Primary signet ring cell carcinoma of the eyelid is a rare neoplasm with less than ten cases described. This report details another case, which shows further parallels to lobular carcinoma of the breast, and reviews the literature on this subject. A 73-year-old white female presented with diffuse induration of her left eyelids. Histopathology revealed a delicate infiltrate of epithelial cells scattered throughout the lid stroma in a non-destructive pattern. The cells were relatively monomorphous and showed only mild atypia and rare mitotic figures. Many had slightly granular amphophilic cytoplasms, others showed distinct signet ring cell morphology, and all were strongly positive for epithelial mucin. Immunomicroscopy showed strong reactivity for estrogen receptor (ER), progesterone receptor (PR) and gross cystic disease fluid protein-15 (GCDFP-15), and was negative for Her-2/neu (erb-2) and cytokeratin 20. An extensive workup for other primary sites was negative. Orbital exenteration showed extensive involvement of both lids and soft tissue, including diffuse muscle and lacrimal gland infiltration. In the breast, signet ring cell carcinoma is considered a variant of lobular carcinoma. The delicate infiltrating pattern in our case and the ER+, PR+, GCDFP-15+, Her-2/neu-phenotype further strengthen this analogy. Together, these data also support apocrine differentiation of primary eyelid signet ring cell carcinoma.

Orbital cellulitis, subperiosteal abscess, sinusitis, and septicemia caused by Arcanobacterium haemolyticum

PURPOSE/METHODS A 16-year-old boy had orbital cellulitis, subperiosteal abscess, sinusitis, and septicemia. Arcanobacterium haemolyticum was identified as the causative organism. RESULTS/CONCLUSIONS This organism is a cause of orbital cellulitis and may require aggresive therapy in order to achieve a therapeutic response.

IgG4 Immunostaining and Its Implications in Orbital Inflammatory Disease

Objective IgG4-related disease is an emerging clinical entity which frequently involves tissue within the orbit. In order to appreciate the implications of IgG4 immunostaining, we analyzed gene expression and the prevalence of IgG4- immunostaining among subjects with orbital inflammatory diseases. Methods We organized an international consortium to collect orbital biopsies from 108 subjects including 22 with no known orbital disease, 42 with nonspecific orbital inflammatory disease (NSOI), 26 with thyroid eye disease (TED), 12 with sarcoidosis, and 6 with granulomatosis with polyangiitis (GPA). Lacrimal gland and orbital adipose tissue biopsies were immunostained for IgG4 or IgG secreting plasma cells. RNA transcripts were quantified by Affymetrix arrays. Results None of the healthy controls or subjects with TED had substantial IgG4 staining. Among the 63 others, the prevalence of significant IgG4-immunostaining ranged from 11 to 39% depending on the definition for significant. IgG4 staining was detectable in the majority of tissues from subjects with GPA and less commonly in tissue from subjects with sarcoidosis or NSOI. The detection of IgG4+ cells correlated with inflammation in the lacrimal gland based on histology. IgG4 staining tissue expressed an increase in transcripts associated with inflammation, especially B cell-related genes. Functional annotation analysis confirmed this. Conclusion IgG4+ plasma cells are common in orbital tissue from patients with sarcoidosis, GPA, or NSOI. Even using the low threshold of 10 IgG4+ cells/high powered field, IgG4 staining correlates with increased inflammation in the lacrimal gland based on histology and gene expression.

Effect of short-duration silicone intubation in congenital nasolacrimal duct obstruction.

Purpose: To determine the incidence of premature dislocation of silicone tubes used in the treatment of congenital nasolacrimal duct obstruction and investigate the effect of early dislocation on treatment outcome. Methods: This retrospective review of 227 cases of silicone intubation in the treatment of 151 patients with congenital nasolacrimal duct obstruction. Specific attention was given to premature tube displacement, persistent epiphora, and the need for reoperation. The effect of the duration of silicone intubation and patient age on surgical outcome was assessed. Significance was determined using a Mantel-Haenszel chi-square test. Results: Tube displacement and removal prior to postoperative day 31 occurred in 93 of 227 (41%) of eyes. Four of 24 eyes (17%) in children younger than 12 months who had premature dislocation of silicone tubes compared with 7 of 40 eyes (18%) that maintained silicone tubes for 31 days or greater had persistent epiphora (p = 0.932); in eyes of children from age 12 months to 23 months, 5 of 46 (11%) had persistent epiphora compared with 6 of 78 (8%) (p = 0.549); and in children age 24 months or older, 9 of 23 (39%) eyes had tearing compared with 3 of 16 (19%) (p = 0.181). Reoperation rates were 1 of 24 (4%) compared with 0 of 40 (0%) (p = 0.23) of eyes in children younger than 12 months; no difference between groups (0%) in children from age 12 months to 23 months; and 5 of 23 (22%) versus 0 of 16 (0%) (p = 0.049) of eyes in children age 24 months or older for early tube removal versus standard tube removal, respectively. Conclusion: Premature tube displacement and tube removal prior to day 31 does not increase the risk of persistent epiphora or reoperation in children younger than 24 months. Children older than 24 months who have early tube removal have poorer outcomes with a significantly higher reoperation rate.

Pneumo-orbital cyst after orbital fracture repair.

PURPOSE To report a case of a respiratory epithelial-lined, air-filled orbital cyst as a late complication of orbital fracture repair. METHOD Case report. RESULTS Recurrent episodes of diplopia and hyperophthalmia developed secondary to pneumatic inflation of a respiratory epithelial-lined orbital cyst 6 months after orbital fracture repair. This cyst remained in communication with an ethmoidal air cell and became inflated during pressurization of the ethmoid sinus. Removal of the cyst and orbital implant was curative. CONCLUSION Air-filled, respiratory epithelial-lined orbital cyst is a rare cause of episodic diplopia and globe displacement after orbital trauma.